Clinical Studies

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Causes and Rates of Unplanned Readmissions After Elective Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

For total hip arthroplasty (THA), the overall pooled readmission rate was 5.6% at 30 days and 7.7% at 90 days. For total knee arthroplasty (TKA), the overall rate was 3.3% at 30 days and 9.7% at 90 days. The leading reason for THA readmission was joint-specific at both 30 and 90 days, and the leading reason for TKA readmission was surgical site infection.

Authors: Ramkumar PN, Chu CT, Harris JD, Athiviraham A, Harrington MA, White DL, Berger DH, Naik AD, Li LT.

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Preventing deep vein thrombosis in hospital inpatients

Most hospital inpatients are at risk of deep vein thrombosis (DVT) and the associated complications of fatal or non-fatal pulmonary embolism and post-thrombotic syndrome. Recognised risk factors for DVT are generally related to one or more elements of Virchow’s triad (stasis, vessel injury, and hypercoagulability), and include surgery, trauma, immobilisation, malignancy, use of oestrogens, heart or respiratory failure, and smoking. Surveillance studies have found that the absolute risk of DVT is 10%-20% among general medical patients and up to 40%-80% in patients having hip surgery, knee surgery, or major trauma .

Authors: Cayley WE Jr.

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Thromboprophylaxis in orthopedic surgery

Pharmacologic thromboprophylaxis with low-molecular-weight heparins, vitamin K antagonists, or fondaparinux is well tolerated and effective in preventing venous thromboembolism (VTE) in major orthopedic surgery but is often limited to in-hospital use. However, 45% to 80% of all symptomatic VTE events occur after hospital discharge. Extended-duration VTE prophylaxis for 28 to 35 days reduces risk for late VTE by up to 70%. In this article, I review the evidence supporting guideline recommendations regarding extended-duration prophylaxis after major orthopedic surgery and provide an overview of current and emerging literature regarding prevention of postoperative VTE in patients undergoing this surgery.

Authors: Muntz J

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Antithrombotic Therapy and Prevention of Thrombosis

In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), we recommend use of one of the following for a minimum of 10 to 14 days rather than no antithrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose vitamin K antagonist (VKA), aspirin (all Grade 1B), or an intermittent pneumatic compression device (IPCD) (Grade 1C).
Remarks: We recommend the use of only portable, battery-powered devices capable of recording and reporting proper wear time on a daily basis for inpatients and outpatients. One panel member believed strongly that aspirin alone should not be included as an option.

Authors: Kearon C, et al. Chest. 2012.

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Thrombosis Prevention after Total Hip Arthroplasty

A Prospective Randomized Trial Comparing a Mobile Compression Device with Low Molecular Weight Heparin.

Results: There was no statistical difference between the groups in the incidence of VTE. Portable sequential devices did show a significant decrease in major bleeding events versus enoxaparin.

Interpretation: If Circul8 can prevent blood clots just as much as a pharmacologic option without the risks of a major bleeding event, the standard hospital protocol should be a baby aspirin and Circul8.

Authors: Colwell CW Jr, et al. J Bone Joint Surg Am. 2010.

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Maternal Death: the Rising National Crisis of Maternal Morbidity and Mortality

Now, the question is how to reduce the national crisis of maternal morbidity and mortality. To reverse increasing maternal mortality, prioritizing venous thromboembolism — the leading medical cause of maternal death in pregnancy — will help lower maternal morbidity and mortality.

Authors: : Niran S. Al-Agba, Michael Wong, JD, John Bianchi

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Venous thromboembolism in the outpatient setting

More VTEs were diagnosed in the 3 months following hospitalization than during hospitalization. Efforts to improve in-hospital use of VTE prophylaxis may help decrease the incidence of outpatient VTE. However, given the shortening of hospital stays, studies of extended VTE prophylaxis following hospital discharge are warranted.

Authors: Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ.

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Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality.

The incidence of pregnancy-related venous thromboembolism was higher than generally quoted. Women ages 35 and older, black women, and women with certain medical conditions and obstetric complications appear to be at increased risk.

Authors: : James AH, Jamison MG, Brancazio LR, Myers ER.

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ACFAS Clinical Consensus Statement

A clinical consensus statement (CCS) of the American College of Foot and Ankle Surgeons (ACFAS):

An effective venous thromboembolism prevention program is typically multimodal and focuses on addressing any modifiable risk factors, use of mechanical prophylaxis, early mobilization, and careful consideration of the use of chemical prophylaxis.

Authors: Adam E. Fleischer, DPM, MPH, FACFAS (Chair), Bradley P. Abicht, DPM, AACFAS, Jeffrey R. Baker, DPM, FACFAS, Troy J. Boffeli, DPM, FACFAS, Daniel C. Jupiter, PhD, Valerie L. Schade, DPM, FACFAS

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Venous Thromboembolism Prophylaxis in the Treatment of Foot and Ankle Disorders

Venous thromboembolism (VTE) consisting of both deep venous thrombosis (DVT) and pulmonary embolism (PE) rates are 1 to 2 per 1,000 person-years and increases with age to 1% per year. The lifetime risk for VTE is approximately 11%. VTE results in more than 100,000 deaths in the US each year.

Authors: Stephan J. LaPointe, DPM, PhD, Karen Moon, DPM

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Risk Factors for the Development of Deep Venous Thrombosis

While the diagnosis and treatment of deep venous thrombosis (DVT) is to a degree straightforward, the decision to institute chemical DVT prophylaxis is more controversial (especially for foot and ankle surgery as compared to knee and hip replacement for example). Some studies show an incidence of thromboembolic events as high as 60% in these patients if not prophylaxed.

Author: Steven R. Carter, DPM

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Antithrombotic Therapies in Spine Surgery

The objective of the North American Spine Society (NASS) Evidence-Based Clinical Guideline on Antithrombotic Therapies in Spine Surgery is to provide evidence-based recommendations to address key clinical questions surrounding the use of antithrombotic therapies in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of February 2008.

Authors: Christopher M. Bono, MD, Committee Chair William C. Watters III, MD, Committee Chair Michael H. Heggeness, MD, PhD Daniel K. Resnick, MD, William O. Shaffer, MD

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Deep Venous Thrombosis in Spine Surgery Patients: Incidence and Hematoma Formation

In the present study, risk factors for each patient were calculated to produce an overall risk factor score, which corresponded from low to very high potential for DVT development. Patients undergoing spinal surgery are at risk of developing VTE.

Authors: : Thair M. Al-Dujaili, Catalin N. Majer, Tarek E. Madhoun, Sebouh Z. Kassis, and Alaa A. Saleh

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Primary prevention of deep venous thrombosis and pulmonary embolism in acute spinal cord injured patients.

The incidence of detected DVT was 2% in those patients (99) admitted early to our centre (within 72 h from the trauma), who immediately received our prophylactic protocol. No PE was reported. The other group of patients (176), all admitted between 8 and 28 days (mean 12 days) developed DVT in 26% of cases. None of these patients received ESPC before being admitted to our Centre. No patient had been admitted between 3 and 8 days interval time post injury.

Authors: Aito S, Pieri A, D'Andrea M, Marcelli F, Cominelli E

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Cold and Compression in the Management of Musculoskeletal Injuries and Orthopedic Operative Procedures: A Narrative Review

Cold and compression are routinely appled immediately after acute injury or following surgery to alleviate pain, reduce swelling and speed functional recovery.

Studies of total knee arthroplasty, in particular, appear to offer an excellent model for evaluating the effects of cold compression on post-operative outcomes. Of the seven randomized trials evaluated, five concluded that cold compression therapy was superior to alternative treatment modalities for improving clinical outcomes after knee replacement surgery.

Authors: Jon E Block, PhD.

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The Role of Cold Compression Dressings in the Posttoperative Treatment of Total Knee Arthroplasty

A prospective randomized study was performed to evaluate the role of cold compressive dressings in the postoperative treatment of total knee arthroplasty (TKA).

The use of cold compression in the postoperative period of TKA results in a dramatic decrease in blood loss. In addition, mild improvements are seen in early return of motion and injectable narcotic pain needs in the postoperative period.

Authors: Levy AS, Marmar E.

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Continuous-Flow Cold Therapy After Total Knee Arthroplasty

Cryotherapy is widely used as an emergency treatment of sports trauma and postoperatively especially after anterior cruciate ligament reconstruction.

The study compared the range of motion, the volume of hemovac output and blood loss, visual analog pain score, analgesic consumption, and wound healing in the 2 limbs of the same patient. This study showed that continuous-flow cold therapy is advantageous after TKA because it provides better results in all areas compared.

Authors: Morsi E.

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Efficacy in Deep Vein Thrombosis Prevention with Extended Mechanical Compression Device Therapy and Prophylaxis Aspirin Following Total Knee Arthroplasty.

The DVT rate for the post-discharge protocol of Aspirin and Portable Mechanical Compression therapy group was 0%. The DVT rate for the post-discharge protocol of just Aspirin group was 23.1%

Authors: Snyder MA, et al. J Arthroplasty. 2017.

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Recommendation 5

We suggest the use of pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolic disease in patients undergoing elective hip or knee arthroplasty, and who are not at elevated risk beyond that of the surgery itself for venous thromboembolism or bleeding.

Grade of Recommendation: Moderate

Authors: Joshua J. Jacobs M.D., Chair, Michael A Mont M.D., Vice Chair, Kevin John Bozic M.D., MBA, Craig J Della Valle, M.D.

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National Patient Safety Goal Addresses Direct Oral Anticoagulants

The prevention of adverse drug events (ADEs) is an important patient safety priority. We’ve learned that anticoagulants are among the most common medications causing adverse drug events. According to the U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, ADEs account for an estimated one-third of hospital adverse events and approximately 280,000 hospital admissions annually.

Authors: Pearl Darling, Executive Director, Ambulatory Health Care

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